Prior Authorization-es

CareSource^® evaluates prior authorization requests based on medical necessity, medical appropriateness, and benefit limits.

Services That Require Prior Authorization

Please refer to the Procedure Code Lookup Tool to check whether a service requires prior authorization. All services that require prior authorization from CareSource should be authorized before the service is delivered. CareSource is not able to pay claims for services in which prior authorization is required, but not obtained by the provider.

• Navigate 2022 Prior Authorization List
• Navigate 2021 Prior Authorization List

Prior Authorization Procedures

The Provider Portal is the preferred and fastest method to request a prior authorization for health care services. You can receive immediate approval and review the status of an authorization.

If you need assistance with submitting your prior authorization or have questions regarding submissions via the portal, please email CiteAutoAssistance@caresource.com and a representative will be in contact. This email is only for assistance and questions regarding prior authorizations within the Provider Portal. For additional information or questions about CareSource benefits, please visit the CareSource Provider Manual or Contact provider services.

Alternate methods include phone, fax or mail.

Phone: 1-800-488-0134, Fax: 1-888-752-0012

Mail: CareSource
P.O. Box 1307
Dayton, OH 45401-1307

Nonparticipating Providers

Prior authorization must be obtained before sending patients to nonparticipating providers, with the following exceptions:

Emergency Services

All in-patient services require prior authorization. Please call 1-800-488-0134 to obtain prior authorization for emergency admissions. Outpatient emergency services do not require prior authorization.

Post Stabilization Services

Prior authorization is not required for coverage of post-stabilization services when these services are provided in any emergency department or for services in an observation setting by a participating provider.

To request prior authorization for observation services as a nonparticipating provider or to request authorization for an inpatient admission, please call 1-800-488-0134 and follow the appropriate menu prompts. During regular business hours, your call will be answered by our Medical Management department.

Please call 1-800-488-0134 for any questions related to post-stabilization services.

Advanced Imaging Prior Authorization

Ordering physicians must obtain prior authorization for the following outpatient, non-emergent diagnostic imaging procedures:

• MRI/MRAs
• CT/CTA scans
• PET scans

Ordering providers can obtain prior authorization from NIA for imaging procedures at RadMD’s website.

Dental Prior Authorization

Starting plan year 2021, Marketplace dental providers can submit a dental authorization request via the DentaQuest Provider Web Portal.